Provider Demographics
NPI:1386136778
Name:NICKENS-GAITHER, TIFFANY AMBER (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:AMBER
Last Name:NICKENS-GAITHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 CONNECTICUT AVE PH SUITE
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5822
Mailing Address - Country:US
Mailing Address - Phone:301-942-2212
Mailing Address - Fax:301-942-1149
Practice Address - Street 1:101 WEST COAST RD
Practice Address - Street 2:#B
Practice Address - City:REDWAY
Practice Address - State:CA
Practice Address - Zip Code:95560
Practice Address - Country:US
Practice Address - Phone:707-923-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62762363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical